P0474 - Nausea, Heartburn, Indigestion, Upset Stomach...Salicylate Toxicity?

Salicylates are among the oldest and most widely used medications to date. They are commonly used for their antipyretic, analgesic, and antithrombotic properties. Even though aspirin or ASA is the most well-known form of salicylate, there are many formulations that can be found over-the-counter. These include salicylic acid, methyl salicylate, and bismuth subsalicylate, which can all cause severe toxicity when ingested or absorbed through skin. In the U.S., there are greater than 20,000 salicylate exposures reported annually in the pediatric population. Majority of these exposures are related to ASA. Consequently, there are limited published reports on subsalicylate formulation in the pediatric population. The following case study highlights the toxic effects of bismuth subsalicylate in the pediatric population and the distinct management required to overcome the severe metabolic derangements associated with it.

This case narrative describes a 6 week old, full term, previously healthy female who initially presented to an outside facility from PCP’s office with irritability, fevers, NBNB emesis, Kussmaul respirations, and pink stools. Lab evaluation revealed severe metabolic acidosis with an anion gap of 27. On further questioning, the patient had ingested several doses of Pepto Bismol Max Strength over a 24 hour period (equating to a salicylate dose of ~100-150 mg/kg). The patient’s initial salicylate level was elevated at 78.7 mg/dL. She was given a 2 mg/kg NaHCO3 bolus and placed on D5W w/ 100 mEq NaHCO3 fluids. Patient was then transferred to the PICU for further evaluation and management.

Serial labs including salicylate level, urine pH, chem14 and EG7 were monitored every 2 hours. Patient was also placed on D5W w/ 150 mEq NaHCO3 and KCl for urine alkalinization. Despite these initial interventions, patient’s salicylate levels continued to rise until a peak ASA of 88 mg/dL. Thereafter, ASA levels trended downwards to a normal range.

Other lab derangements included metabolic acidosis, hypokalemia, hypocalcemia, transaminitis, elevated CPK, elevated coagulation studies, and anemia. Electrolytes were frequently replaced using calcium gluconate, calcium chloride, and potassium chloride. Transaminitis and CPK levels normalized as ASA levels improved. PRBC transfusion was given for anemia. Additionally, a respiratory panel was conducted due to concerns of possible Reye’s syndrome, which was negative. Ultimately, after a week-long hospital stay, the patient's clinical status improved as her labs normalized and was discharged home.

This case not only demonstrates the severe consequences of unintentional overdose of a common OTC medication but also the unlikelihood of subsalicylate toxicity in the infant population given its intended use in individuals ages 12 years and older. The study emphasizes the importance of recognizing a rare clinical presentation which leads to the appropriate diagnosis and treatment to avoid possible demise.